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  • Placement of other sutures done by Interrupted sutures Single running suture Double running suture Interrupted sutures  recommended in infants and children, highly vascularized corneas and therapeutic Keratoplasty Knots buried beneath epithelium of recipient or donor ( preferred in donor to reduce risk of vascularization)
  • Post operative care of a graft is important in determining long term outcome of the graft
  • Keratoplasty

    1. 1. KERATOPLASTY Gauri S. Shrestha, M.Optom, FIACLE
    2. 2. Introduction <ul><li>Keratoplasty is the corneal transplant procedure in which diseased host corneal tissue is excised and replaced with healthy donor cornea </li></ul><ul><li>The objectives are to: </li></ul><ul><ul><li>Establish clear corneal visual axis </li></ul></ul><ul><ul><li>Minimize refractive error </li></ul></ul><ul><ul><li>Provide tectonic support </li></ul></ul><ul><ul><li>Alleviate pain </li></ul></ul><ul><ul><li>Eliminate infection </li></ul></ul>
    3. 3. Indication <ul><li>Optical: to improve visual acuity </li></ul><ul><li>Corneal scars (4) </li></ul><ul><li>Corneal dystrophies/degenerations (1) </li></ul><ul><li>Congenital corneal opacities (3) </li></ul><ul><li>Keratoconus (2) </li></ul>
    4. 4. Optical indications 1 2 3 4
    5. 5. Indication: <ul><li>Tectonic and reconstructive </li></ul><ul><li>Restoration of altered corneal structure </li></ul><ul><li>Corneal perforations/thinning </li></ul>Tectonic PK also improves visual function and the option for future optical graft remains viable
    6. 6. Indications <ul><li>Therapeutic </li></ul><ul><li>Tissue substitution for corneal diseases </li></ul><ul><li>Non healing corneal ulcer ( Infectious keratitis) </li></ul><ul><li>Elimination of pain in case of corneal edema eg bullous keratopathy </li></ul><ul><li>Cosmetic </li></ul><ul><li>For unsightly corneal scars with no visual potential </li></ul><ul><li>To restore the normal appearance of eye </li></ul>
    7. 7. Therapeutic indication
    8. 8. Types of corneal graft <ul><li>Lamellar keratoplasty (partial) </li></ul><ul><ul><li>Removing the superficial part of corneal tissue without entering the anterior chamber </li></ul></ul><ul><ul><li>Anterior lamellar </li></ul></ul><ul><ul><li>Posterior lamellar </li></ul></ul><ul><li>Penetrating keratoplasty (Full) </li></ul>
    9. 9. Lamellar graft in Granular dystrophy
    10. 10. Lamellar graft in marginal ulcer:
    11. 11. Penetrating keratoplasty <ul><li>Full thickness replacement of diseased tissue with healthy donor cornea </li></ul><ul><li>Indications: </li></ul><ul><li>Pathology involving whole cornea </li></ul><ul><li>full thickness scars </li></ul><ul><li>Perforation of cornea </li></ul><ul><li>Herpetic scars </li></ul><ul><li>vascularized scars </li></ul><ul><li>Keratoconus </li></ul>
    12. 12. Donor selection <ul><li>Contraindications </li></ul><ul><ul><li>Death of unknown cause </li></ul></ul><ul><ul><li>CNS disease </li></ul></ul><ul><ul><li>Infectious encephalitis, Rubella </li></ul></ul><ul><ul><li>Infectious diseases like HIV, Hepatitis, Septicemia, Syphilis, Endocarditis </li></ul></ul><ul><ul><li>Eye disease like ocular malignancy </li></ul></ul>
    13. 13. Donor selection <ul><li>Contraindications </li></ul><ul><ul><li>Active ocular inflammation like uveitis, scleritis, retinitis,choroiditis </li></ul></ul><ul><ul><li>Prior ocular surgery </li></ul></ul><ul><ul><li>Congenital or acquired anterior segment abnormality eg: Keratoconus, Fuch’s endothelial dystrophy </li></ul></ul>
    14. 14. Pre operative evaluation <ul><li>Evaluation of visual potential </li></ul><ul><li>Ocular surface abnormalities inflammation </li></ul><ul><li>Increased IOP </li></ul><ul><li>Corneal vascularization </li></ul><ul><li>Adherent leucoma </li></ul><ul><li>Peripheral corneal thinning </li></ul><ul><li>Status of lens, vitreous, retina , optic nerve </li></ul>
    15. 15. Trephination of donor cornea <ul><li>Recommended that donor corneal button be cut before the recipient cornea </li></ul><ul><li>Graft host disparity: </li></ul><ul><ul><li>Selection of graft size depends on planned diameter of host (recipient) cut </li></ul></ul><ul><ul><li>If diameter of recipient bed is > than 9mm or < than 7mm – graft larger than host by 1mm </li></ul></ul><ul><ul><li>Some surgeons use 0.5mm oversized donor graft for all cases and 1mm in cases of severe irido corneal scars </li></ul></ul>
    16. 16. Preparation for surgery <ul><li>Anesthesia: </li></ul><ul><ul><li>Local anesthesia </li></ul></ul><ul><ul><li>General anesthesia – pediatric pts, uncooperative, mental impairment, perforated corneas, inflamed eyes </li></ul></ul><ul><li>Dressing and draping </li></ul><ul><li>Exposure and insertion of lid speculum </li></ul><ul><li>Fixation of the globe </li></ul>
    17. 17. Suturing of donor cornea: <ul><li>Placement of donor cornea on recipient </li></ul><ul><li>Anterior chamber of recipient filled with viscoelastics </li></ul><ul><li>Donor cornea brought into field of microscope with a graft holder </li></ul><ul><li>Kept on the inferior limbus of recipient, grasped with a forceps and brought to superior edge </li></ul>
    18. 18. Suturing of donor cornea <ul><li>Sutured to recipient cornea with 10 – 0 </li></ul><ul><li>nylon sutures with a cutting needle </li></ul><ul><ul><li>Necessary to place 4 cardinal sutures first at 90 deg interval </li></ul></ul><ul><ul><li>First suture at 12 O’clock, 2 nd at 6 O’clock followed at 3 O’clock and 9 O’clock </li></ul></ul><ul><li>Full thickness suture avoided to minimize endothelial trauma and leakage of aqueous </li></ul><ul><li>Total of 16 sutures are usually placed for a 8mm diameter graft </li></ul>
    19. 20. Post operative care <ul><li>Intraoperative </li></ul><ul><ul><li>Subconjunctival corticosteroid and antibiotic, eye patching for 24 hours </li></ul></ul><ul><li>1 st post op. day </li></ul><ul><ul><li>Assessment of visual acuity </li></ul></ul><ul><ul><li>Degree of pain </li></ul></ul><ul><ul><li>Slit lamp examination </li></ul></ul>
    20. 21. Post operative care <ul><ul><li>Topical medication </li></ul></ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul><ul><ul><ul><li>Steroids </li></ul></ul></ul><ul><ul><ul><li>Anti glaucoma </li></ul></ul></ul><ul><ul><ul><li>Cycloplegics </li></ul></ul></ul><ul><ul><ul><li>Lubricants </li></ul></ul></ul>
    21. 22. Final spectacles prescribed after 24 months when sutures are removed Post operative PK outpatient schedule Every 2-4 months until all sutures are removed Every month Every 2 weeks Every week Month 13-24 Month 3-12 Month 2 Month 1
    22. 23. Donor tissue evaluation <ul><li>Gross evaluation before retrieval </li></ul><ul><li>Drying, erosion, haze, scars, signs of conjunctivitis, discharge </li></ul><ul><li>Congenital abnormalities, previous surgery </li></ul><ul><li>Slit lamp evaluation </li></ul><ul><li>Faint scars, erosions, senile arcus, </li></ul><ul><li>Stromal edema, thickness, infiltrates </li></ul>
    23. 24. Donor tissue evaluation <ul><li>Specular microscopy </li></ul><ul><li>Endothelial cell density </li></ul><ul><ul><li>Cut off endothelial cell density : 1500 to 2200/mm2 </li></ul></ul><ul><li>Variation in cell shape /size and any abnormality </li></ul>
    24. 25. Classification of donor cornea on the basis of suitability <ul><li>Excellent </li></ul><ul><li>Crystal clear cornea </li></ul><ul><li>No epithelial defect </li></ul><ul><li>No striae </li></ul><ul><li>No endothelial defect </li></ul><ul><li>Very good </li></ul><ul><li>Clear cornea </li></ul><ul><li>Slight epithelial haze or defect </li></ul><ul><li>Few light folds /striae </li></ul><ul><li>No guttata </li></ul><ul><li>Good </li></ul><ul><li>Light cloudiness </li></ul><ul><li>Obvious epithelial defect </li></ul><ul><li>Numerous light folds </li></ul><ul><li>Few guttata </li></ul><ul><li>Fair </li></ul><ul><li>Moderate cloudiness </li></ul><ul><li>Rough epithelium </li></ul><ul><li>Numerous dense folds </li></ul><ul><li>Moderate guttata </li></ul>
    25. 26. Optical PK for congenital hereditary endothelial dystrophy
    26. 27. ALK for keratoconus 3 months post op
    27. 28. Pre and post Op TPK
    28. 29. Post op TPK for perforated corneal ulcer 1 year
    29. 30. Surgical retrieval <ul><li>Enucleation </li></ul><ul><li>In situ Excision </li></ul><ul><li>Corneo-scleral Rim sectioning </li></ul><ul><li>Can be performed in </li></ul><ul><ul><li>An operating theatre </li></ul></ul><ul><ul><li>Morgue </li></ul></ul><ul><ul><li>Hospital room </li></ul></ul><ul><ul><li>Funeral room </li></ul></ul>
    30. 31. Surgical retrieval <ul><li>Rinse the globe in dilute povidine Iodine solution (10% solution) for 1-2 min </li></ul><ul><li>Followed by thorough rinse </li></ul>
    31. 32. Storage: Short term method <ul><li>Moist chamber technique </li></ul><ul><ul><li>Whole globe is preserved at 4 degree centigrade with saline humidification for up to 48 hours. </li></ul></ul><ul><ul><li>Simple, cheap, easily transportable, and requires minimum manipulation. </li></ul></ul>
    32. 33. Storage: Intermediate term method <ul><li>McCarey—Kaufman (MK) medium : can preserve cornea for upto 4 days at 4 degree centigrade </li></ul><ul><li>Chondroitin sulphate enriched media </li></ul><ul><ul><li>Dexsol medium. </li></ul></ul><ul><ul><li>Lysol medium </li></ul></ul><ul><li>Optisol Medium: It contains dextran and chondroitin sulphate which enhances corneal dehydration during storage and the cornea can be preserved for 14 for days </li></ul>
    33. 34. Storage: Long term method <ul><li>Organ culture method : It can store cornea for 35 days </li></ul><ul><li>Cryopreservation Methode : (Capella and Kaufman). </li></ul><ul><li>It can preserve the cornea for an indefinite time. </li></ul><ul><li>The corneoscleral rim is removed from the eye ball and stored at minus 160 degree centigrade indefinitely </li></ul>While storing and shipping the cornea, endothelium must be kept upright
    34. 35. Ingredients of the medium <ul><li>Sodium Pyruvate, Glucose: Energy supplies. </li></ul><ul><li>Amino Acids,Mineral salts,Serum: Nutrients. </li></ul><ul><li>Trophic factors </li></ul><ul><li>Penicillin G, Streptomycin, Nystatin:Antibiotics. </li></ul><ul><li>Hepes buffer, Bicarbonate: pH buffes </li></ul><ul><li>Phenol Red:Colour indicator. </li></ul><ul><li>Dextran: Osmotic agent. </li></ul>
    35. 36. Medicolegal aspect of Cornea donation <ul><li>Ethics for Eye Bank </li></ul><ul><li>Corneas/eyeball should not be removed during life. </li></ul><ul><li>Eye tissues should not be either bought or sold. </li></ul><ul><li>The identity of the recipient or donor should not be disclosed to each other. But the donor party may be informed that the tissue is used for surgery </li></ul><ul><li>Eye tissue should not be distributed with discrimination based on caste, creed, color or nationality. </li></ul>
    36. 37. Ethics cont… <ul><li>Tissues should always be exchanged freely between eye banks </li></ul><ul><li>The donor identity should not be revealed to the surgeon. </li></ul><ul><li>The eye tissue should be distributed only to the qualified eye surgeon or ophthalmologist </li></ul><ul><li>The contraindicated corneal tissues should not be used for the transplant </li></ul>
    37. 38. Ethics cont… <ul><li>After the use of cornea, or not suitable for surgery, it should be disposed in any of the following ways </li></ul><ul><ul><li>Study of histopathology of eye of it’s various parts </li></ul></ul><ul><ul><li>For research purpose </li></ul></ul><ul><ul><li>Preservation of sclera and cornea </li></ul></ul><ul><ul><li>The rest of the unused donor tissue should be disposed of by incineration </li></ul></ul>
    38. 39. Thank you